ISSN: 2320-5407 Int. J. Adv. Res.

12(06), 775-780

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/18939
DOI URL: http://dx.doi.org/10.21474/IJAR01/18939

RESEARCH ARTICLE
DERMOID CYST IN CANAL OF NUCK: A CASE REPORT

Sobhy Mohamed Ismail Amer(1), Hanaa Mohamed Mansour(2) and Areej Al Shihabi(3)
1- Specialist General and Laparoscopic Surgeon, HMS-AL Garhoud Hospital - Dubai, UAE.
2- Specialist Obestetrics and Gynecology, Midcare Hospital - Sharjah, UAE.
3- Specialist General and Breast Surgeon, KSA, USA.
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Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Canal of Nuck in females is corresponding to processus vaginalis in
Received: 20 April 2024 males.Defects in canal of Nuck are rare conditions that appears usually
Final Accepted: 24 May 2024 early in young females.Failure of complete obliteration of the canal of
Published: June 2024 Nuckresults in an indirect inguinal hernia or a hydrocele of the canal.In
this study, we present a 28 year old married lady with cystic lesion in
Key words: -
NuckCyst, Cyst of the Canal of Nuck, the right inguinal canal diagnosed as- cyst of canal of Nuck.Surgical
Hydrocele, Hernia, Inguinal, Canal excision was done plus repair of canal defect using proline mesh.
OfNuck, Rare Diseases

Copy Right, IJAR, 2024,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Anatomical and Pathological Background
In 1691, Anton Nuck, a Dutch anatomist, was the first to describe the canal of Nuck (1). The canal of Nuck is the
female equivalent to the processus vaginalis in males, which usually disappears within the first year of life. It
consists of an evagination of peritoneum, which is attached to the uterus by the round ligament, and proceeds
through the inguinal ring alongside the round ligament into the labia majora (2,3). Usually, the superior part of this
outpouch obturates during or just before birth and disappears within the first year of life. In rare cases, this
obturation fails, resulting in a persistence of the canal of Nuck (2,4,1) (Figure 4), which can cause the formation of a
female hydrocele, namely the cyst of the canal of Nuck (5,6). This phenomenon in women was first reported by
Coley in 1892 (7). Similar to the male hydrocele, a female hydrocele probably arises due to an imbalance of
secretion from and absorption of fluid by the secretory membranes of the canal of Nuck (2,8). Although this
imbalance is most frequently idiopathic, disturbed lymphatic drainage caused by trauma, infection or inflammation
are other possible reasons (3,9).

Case Presentation
A 28-year-old female with no past history of chronic diseases, had history of two vaginal deliveries, presented to
emergency department with a pain in the right lower abdomen, suspected for acute appendicitis. Abdominal
ultrasound was done that revealed a cystic swelling in the right inguinal canal, for better pelvic MRI evaluation. The
patient reported she never suffered from regional pain before, there was no history of local trauma, symptoms of
nausea, vomiting or abdominal discomfort. Her body mass index was 28 kg/m2. Her medical history was negative
for any pathology and surgical procedures. She had two uncomplicated vaginal deliveries. At presentation, physical
examination revealed a small palpable mobile lump in the right groin without overlying skin erythema or tenderness.
Valsalva maneuver did not make the mass more prominent. There was an absence of incarceration or strangulation.
Her abdomen was soft, non-distended and non-tender with no signs of bowel occlusion. Laboratory tests showed
measured parameters were within the normal range. Magnetic resonance imaging (MRI) revealed 7.8x3 cm oblong

Corresponding Author:- Sobhy Mohamed Ismail Amer 775

Address:- Specialist General and Laparoscopic Surgeon,HMS Al Garhoud Hospital -
Dubai, UAE.
ISSN: 2320-5407 Int. J. Adv. Res. 12(06), 775-780

cystic swelling occupying the right inguinal canal and protruding to the subcutaneous tissue, there was no evidence
of bowel loops, omentum or other solid structures within the mass. The diagnosis of a Nuck cyst was considered, the
cyst was not painful, patient was managed conservatively and planned for elective excision of the cyst plus repair of
the canal defect.

Figure 1:- A schematic of the female anatomy and the patent canal of Nuck.

The cyst was dissected from the round ligament and was completely excised. The defect of the internal inguinal ring
was repaired with the use of a mesh. Histology sections revealed- rounded unilocular cavity having a wall lined by
keratinized stratifiedsquamous epithelium of variable thickness with prominent granular cell layer resembling
skinepidermis with skin appendages including hair follicles, sweat glands, sebaceous glands, the cyst is filled with
horny material arranged in laminated layers, the extruded keratin provoked a foreign-body reaction in the adjacent
dermis with heavy mixed inflammatory cell infiltrate. Diagnosis is- Dermoid cyst in canal of Nuck.

The patient's postoperative course was uneventful, and she was discharged the next day. Sex months
postoperatively, the patient remained asymptomatic without any recurrence. Written informed consent was obtained
from the patient for publication of this case study and any accompanyingimages.

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Figure 2:- Pelvis MRI (with and without contrast) showing a thin-walled cystic structure located in the right groin.

Discussion:-
The Canal of Nuck runs through the inguinal canal adjacent to the round ligament and is considered the female
analogue of the processus vaginalis in males (16). Normally, the Canal of Nuck is obliterated within the first year of
life. Failure of the Canal to close during that period in female infants can result in Nuck hydrocele or herniation of
intraabdominal structures through the patent Canal of Nuck (10). Thus, failure of closure is typically detected in
childhood. Due to its rarity, accurate information regarding the exact prevalence of hydrocele during childhood is
not available. Akkoyun et al (17) reported that only 0.76% of girls <12 years exhibited hydrocele of Nuck among
their study population. A comparable prevalence of Nuck hydrocele (0.74%) was also reported by Papparella et al

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(18), who reviewed 353 female patients, aged 1-14 years, with inguinal swelling. Literature regarding Nuck
hydrocele in adulthood are even more scarce.

At clinical examination, the cyst of the Canal of Nuck is frequently described as a painless or mildly painful
reducible or irreducible mass in the inguinal region, which typically extends to the labia majora, and does not
expand when performing the Valsalva maneuver (14). Differential diagnosis includes inguinal hernia, enlarged
lymph nodes and soft tissue tumours such as lipomas, leiomyomas and endometriosis of the round ligament (19).

Figure 3:- Anatomy of the inguinal canal with a physiologically obliterated Canal of Nuck and the potential sites of
the cyst through the canal when it remains patent.

Anatomy of the inguinal canal with a physiologically obliterated Canal of Nuck and the potential sites of the cyst
through the canal when it remains patent.

A cyst of the Canal of Nuck is frequently misdiagnosed as inguinal hernia in females and is only correctly diagnosed
intraoperatively. Therefore, preoperative imaging is crucial for diagnosis and further therapeutic options. Imaging
with MRI allows a good visualization of the anatomic structures surrounding the cyst, communication between the
cyst and the peritoneal cavity and the extension of the cyst of the Canal of Nuck (13). However, despite the utility of
imaging in differential diagnosis, surgery along with histological and immunohistological analysis of the excised
mass is required for a more conclusive diagnosis of a Nuck cyst.

Another issue that should be addressed is the association of the pathology of the Canal of Nuck with fertility. In the
published literature, there was only one association with infertility; a nulliparous woman of reproductive age who
underwent simultaneous ovarian cyst excision and repair of patent Canal of Nuck (12). Postoperative courses of all
published cases are uneventful. Unfortunately, data concerning postoperative fertility was not available for any of
the reported cases but in this case, patient gave her third baby three years after cyst excision- vaginal delevary. Other
pathologies of the Canal of Nuck such as ovary herniation or endometriosis of the canal may result in infertility in
young females (20).

Surgical management of a cyst of the Canal of Nuck includes open or laparoscopic excision of the cystic structure
with concomitant closure of the inguinal internal defect primarily with the use of a mesh (15,21,22). The appropriate

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surgical approach is tailored based on the extent of the disease, the accuracy of preoperative diagnosis and the co-
existence of an inguinal hernia. In the case of concomitant identification of an inguinal hernia, an additional hernia
repair with or without mesh placement can be safely performed. Furthermore, as described by Ferreira et al (11), an
additional vulva correction may be indicated in cases of mass extension to the labia majora.

Due to limited data from case reports and small case series, the actual prevalence of Nuck cyst could not be
precisely estimated. The significant heterogeneity among the included studies along with the lack of mention of
certain parameters by some authors were additional limitations.

Conclusion:-
The cyst of the canal of Nuck is a rare condition, but it should be included in the differential diagnosis list of
inguinal tumours in female patients.A focused physical examination followed by high-resolution sonography
enables the diagnosis of a cyst of the canal of Nuck. To plan an adequate surgical intervention, cross-sectional
imaging, preferably MRI, allowing clarification of the anatomical conditions is of utmost importance. Our review
provides insight into the anatomical background, diagnostics, and surgical intervention of a cyst of the canal of
Nuck.

References:-
1. Nuck, A. Adenographia curiosa et uteri foemineianatome nova. Am. J. Obstet. Gynecol. 1975, 123, 66. [Google
Scholar] [CrossRef].
2. Nasser, H.; King, M.; Rosenberg, H.K.; Rosen, A.; Wilck, E.; Simpson, W.L. Anatomy and pathology of the
canal of Nuck. Clin. Imaging 2018, 51, 83–92. [Google Scholar] [CrossRef] [PubMed].
3. Zawaideh, J.P.; Trambaiolo Antonelli, C.; Massarotti, C.; Remorgida, V.; Derchi, L.E. Cyst of Nuck: A
Disregarded Pathology. J. Minim. Invasive Gynecol. 2018, 25, 376–377. [Google Scholar] [CrossRef]
[PubMed].
4. Holley, A. Pathologies of the canal of Nuck. Sonography 2018, 5, 29–35. [Google Scholar] [CrossRef].
5. Prodromidou, A.; Paspala, A.; Schizas, D.; Spartalis, E.; Nastos, C.; Machairas, N. Cyst of the canal of Nuck in
adult females: A case report and systematic review. Biomed. Rep. 2020, 12, 333–338. [Google Scholar]
[CrossRef] [PubMed].
6. Kim, K.S.; Choi, J.H.; Kim, H.M.; Kim, K.P.; Kwon, Y.J.; Hwang, J.H.; Lee, S.Y. Hydrocele of the canal of
nuck in a female adult. Arch. Plast. Surg. 2016, 43, 476–478. [Google Scholar] [CrossRef] [PubMed].
7. Coley, W.B., II. Hydrocele in the Female: With a Report of Fourteen Cases. Ann. Surg. 1892, 16, 42–59.
[Google Scholar] [CrossRef].
8. Dagur, G.; Gandhi, J.; Suh, Y.; Weissbart, S.; Sheynkin, Y.R.; Smith, N.L.; Joshi, G.; Khan, S.A. Classifying
Hydroceles of the Pelvis and Groin: An Overview of Etiology, Secondary Complications, Evaluation, and
Management. Curr. Urol. 2017, 10, 1–14. [Google Scholar] [CrossRef].
9. Ozel, A.; Kirdar, O.; Halefoglu, A.M.; Erturk, S.M.; Karpat, Z.; Lo Russo, G.; Maldur, V.; Cantisani, V. Cysts
of the canal of Nuck: Ultrasound and magnetic resonance imaging findings. J. Ultrasound 2009, 12, 125–127.
[Google Scholar] [CrossRef] [PubMed].
10. Rees MA, Squires JE, Tadros S and Squires JH: Canal of Nuck hernia: A multimodality imaging review.
PediatrRadiol. 47:893–898. 2017.PubMed/NCBI View Article : Google Scholar.
11. Ferreira AF, Marques JP and Falcao F: Hydrocele of the canal of Nuck presenting as a sausage-shaped mass.
BMJ Case Rep 2017: pii: bcr-2017-221024, 2017.
12. Yen CF, Wang CJ, Chang PC, Lee CL and Soong YK: Concomitant closure of patent canal of Nuck during
laparoscopic surgery: Case report. Hum Reprod. 16:357–359. 2001.PubMed/NCBI View Article : Google
Scholar.
13. Kono R, Terasaki H, Murakami N, Tanaka M, Takeda J and Abe T: Hydrocele of the canal of Nuck: A case
report with magnetic resonance hydrography findings. Surg Case Rep. 1(86)2015.PubMed/NCBI View Article :
Google Scholar.
14. Sethi V and Patel H: Hydrocele in the Canal of Nuck-CT appearance of a developmental groin anomaly. J
Radiol Case Rep. 10:29–33. 2016.PubMed/NCBI View Article : Google Scholar.
15. Ryan JD, Joyce MR, Pierce C, Brannigan A and O'Connell PR: Haematoma in a hydrocele of the canal of Nuck
mimicking a Richter's hernia. Hernia. 13:643–645. 2009.PubMed/NCBI View Article : Google Scholar.
16. Choi YM, Lee GM, Yi JB, Yoon KL, Shim KS, Bae CW, Choi SI and Kim HC: Two cases of female hydrocele
of the canal of nuck. Korean J Pediatr. 55:143–146. 2012.PubMed/NCBI View Article : Google Scholar.

779
ISSN: 2320-5407 Int. J. Adv. Res. 12(06), 775-780

17. Akkoyun I, Kucukosmanoglu I and Yalinkilinc E: Cyst of the canal of nuck in pediatric patients. N Am J Med
Sci. 5:353–356. 2013.PubMed/NCBI View Article : Google Scholar.
18. Papparella A, Vaccaro S, Accardo M, De Rosa L, Ronchi A and Noviello C: Nuck cyst: A rare cause of
inguinal swelling in infancy. Minerva Pediatr: Jul 23, 2018 (Epub ahead of print).
19. Stickel WH and Manner M: Female hydrocele (cyst of the canal of Nuck): Sonographic appearance of a rare
and little-known disorder. J Ultrasound Med. 23:429–432. 2004.PubMed/NCBI View Article : Google Scholar.
20. Choi KH and Baek HJ: Incarcerated ovarian herniation of the canal of Nuck in a female infant:
Ultrasonographic findings and review of literature. Ann Med Surg (Lond). 9:38–40. 2016.PubMed/NCBI View
Article : Google Scholar.
21. Bagul A, Jones S, Dundas S and Aly EH: Endometriosis in the canal of Nuck hydrocele: An unusual
presentation. Int J Surg Case Rep. 2:288–289. 2011.PubMed/NCBI View Article : Google Scholar.
22. Jimenez JS, Barbero P, Tejerizo A, Guillen C and Strate C: A laparoscopic approach to Nuck's duct
endometriosis. FertilSteril. 96:e103–e105. 2011.PubMed/NCBI View Article : Google Scholar.

780